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In this study, Borderie et al demonstrate long-term advantages of deep anterior lamellar keratoplasty (DALK) compared to penetrating keratoplasty (PK) in the treatment of keratoconus. In particular, they noted differences in long-term endothelial cell count and tendency to develop ocular hypertension favoring the DALK group. This is one of the largest studies on this topic; it provides long-term insight due to its extended follow-up period, and it reinforces the findings published in a previous report from the same group.1
While the current body of evidence suggests that DALK may be comparable in some ways, and superior in others to PK, in this long-term follow-up, single surgeon study that included 502 eyes, with approximately a quarter followed-up for 15 years or more, the authors provide compelling evidence that DALK is advantageous to PK in keratoconus eyes. However, PK led to favorable results, as well.
Despite the advent of the Big Bubble technique, DALK remains a more complex surgery compared with PK, and requires a steeper surgeon learning curve.2 DALK also carries the risk of graft–host stromal interface opacification, particularly if the depth of stromal dissection is insufficient, which may be one of many reasons for suboptimal visual results reported by others after manual pre-Descemetic DALK.3 In fact, the same group has highlighted this disadvantage in its 5-year follow-up report, in which PKs had better visual outcomes …
Contributors Both authors contributed to this manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.